Page 1

Reaching Out

Weaving a rich tapestry of patient care across the Mountain West

2014 NURSING REPORT


1. Connect depth with breadth. page 3

2. Talk with the patient, not about the patient. page 7 3. Give tiny patients a perfect start. page 12

Reaching Out: 10 ways nurses are weaving a rich tapestry of patient care across the Mountain West 4. Stand up for patient safety. page 15

5. Tap into talent statewide. page 18 6. Break big challenges into practical parts. page 21 7. See the science of work spaces. page 24 8. Get your patients coming and going. page 26 9. Chart a course for home. page 29 10. Elevate your workforce. page 32


A message from our Chief Nursing Officer

This year our report is focused on reaching out, and we are highlighting what nurses in the Mountain West are doing to share knowledge with each other and improve the health of our patients. Our report not only includes nurses at the University of Utah Health Care, but we are dedicating our report to nurses in other organizations whom we have met and learned from on our outreach journey this year. You will read about a group of nurses in rural Utah who came to work with us to gain high-risk OB, operating room, and PICC line experience and in the process taught us about bedside report, which has dramatically improved our patient experience with communication. You will hear from Carson Tahoe in Carson City, Nevada, who will share their journey that led to their Baby Friendly designation, and from St. John’s Hospital in Jackson, Wyoming, who has improved patient safety with a daily leadership huddle. And from our own nurses you will read about our journey of process improvement and how we have reached out within our organization and across the country to learn new and better ways of caring for our patients. We are excited to deliver this report to you and honored to introduce all the wonderful nurses we have met reaching out. And as always, we invite you to reach out to us at NursingInnovation.UofUHealth.org to share your ideas and ways we can better care for our patients.

Margaret Pearce, RN, PhD Chief Nursing Officer University of Utah Health Care


Customized training opportunities: RN Brenda Pomrenke from Community Hospital in Grand Junction, Colorado, connects with RN Marissa Rabara at the U’s Surgical Intensive Care Unit.

01. Connect depth with breadth.

Advancing patient care through rural and urban partnerships 2014 NURSING REPORT / 3


39 Nurses 1,392 Training Hours In the first year of the rural outreach program, the University partnered with 6 different rural hospitals in Utah and Wyoming for onsite training and clinical shifts.

Across the 85,000 square miles of Utah, 80 percent of the state’s populations of 2.9 million live in and around the Salt Lake valley and neighboring communities. Located in the heart of this metro area, the University of Utah Health Care provides care across a broad continuum, from primary care to tertiary and quaternary specialty services. We are a level one trauma center, and our nurses are highly specialized in their area and very proud of the depth of their expertise. Outside of the metro area, the remaining 580,000 Utahns are spread across the state in rural communities, where the hospital is most always a focal point. Here in these vital smaller towns, patients are also neighbors and friends, served by physicians and nurses with a vast breadth of expertise. These nurses can do it all, from caring for emergencies, to working in the operating room, to delivering the community’s next generation in labor and delivery. They are highly experienced and very proud of their ability to manage whatever comes their way in a wide range of areas.

So what happens when depth meets breadth? A few years ago, a group of nine rural hospital CNOs in Utah—known as The Nine—met with us onsite here at the University of Utah, and during the discussions, we explored how to provide additional experience for their nurses for situations that are less frequent in a rural setting. The rural CNOs all had staff experts in skills like PICC line placement and high-risk labor and delivery. But keeping skills fresh is always a challenge when you don’t have the opportunity to use them every day. Partnering with Brenda Bartholomew, Chief Nursing Officer of Gunnison Hospital and chair of The Nine, we did a needs assessment with our rural colleagues and designed a training experience that includes not only

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classroom instruction, but also allows time for patient simulation, hands-on demonstration, and clinical time with our staff nurses on shift. As part of our teaching mission, we were fortunate to already have in place the paperwork and processes necessary to bring clinical

“ Their dedication to this training inspired me. Most of these nurses would travel hours to our hospital for the trainings, but they were more than happy to do it, and we found we learned from them as we worked together.” — Kim Meyer Nurse Educator, Labor and Delivery

nurses into our environment. The three areas that we focused on initially were PICC line placement, high-risk labor and delivery, and operating room procedures for nurses, and we have since added emergency and critical care. To deliver the best possible learning experience and also accommodate the number of nurses who can be away from their hospitals simultaneously, we identified the number of open slots for each experience and invited the 9 hospitals to send one or two nurses at a time.

Customized training for experienced nurses We started by giving the nurses a full tour of our facilities to get them acquainted with the hospital. For nurses in the PICC line placement training, the first day begins with classroom training, reviewing the clinical aspects of the procedure and going over a skills checklist, and hands-on training with an arm manikin. The next day they work side-by-side with our PICC team going


from case to case in the hospital placing PICC lines. The high-risk labor training starts with a realistic team simulation and debrief (see last year’s nursing report story #6), followed by two 12-hour nursing shifts where the rural nurse is partnered with one of our nurses providing direct care to our patients. For the operating room learning process, nurses spend time working in the hospital operating rooms in the specialty they want to focus on and also travel to multiple outpatient facilities to receive the training that is pertinent to their practices. At the end of the week, time is reserved if requested for a didactic session with the OR Educator answering questions about what was observed and providing additional training specifically tailored to the individual nurses. Each experience is tailored to the visiting staff.

nurses were very knowledgeable and were anxious to learn as much as possible in the little time they had. We found them all to be very flexible, creative, and resourceful.”

Immediately our staff noted a most delightful difference in working with these experienced nurses. “We are so used to training students or new orientees,” said Tiffany Noss, Clinical Staff Educator. “These experienced rural

Learning from each other

Kim Meyer, Labor and Delivery Nurse Educator, was at first unsure of how to shape the learning experience for rural nurses. “I’ve worked in a large academic medical center my entire career, so I really had no frame of reference for community hospitals.” She quickly realized that they had very little need for basic training, and could jump right into the specialized materials. “Their dedication to this training inspired me. Most of these nurses would travel hours to our hospital for the trainings, but they were more than happy to do it, and we found we learned from them as we worked together.”

As part of the training partnership, we emphasized to the group of rural nurses that we wanted the opportunity to

A resource for establishing solutions: RN Kurtis Ence from Mountain West Medical Center in Tooele, Utah works with RN Patricia Huot-Kentch at the U as he builds a new PICC team for his organization.

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learn from them during their time with us. “I’ve always been open to the fact that there are many different ways of doing things, and we can learn as much from rural nurses as we teach,” said Margaret Pearce, CNO at University of Utah Health Care. “As we went through the training, we wanted to take advantage of their visit to learn from their experiences as well and urged them to speak up with any comments or questions that they had in regards to their own experiences.” It was during one of these exchanges that we learned about Gunnison Hospital’s Bedside Report initiative, and we quickly took the opportunity to send our nurse leaders to their hospital to watch and learn from their success (see story #2). Quick trip to Salt Lake City: The U’s AirMed keeps us closely connected and provides extra support for critical situations in Sweetwater County.

Across the Utah border “Memorial Hospital of Sweetwater County is located in the southwest corner of Wyoming and has served our community since 1894, when it was built to serve the mining workers in this region. Our partnership with the University of Utah Health Care over the past few years has resulted in sharing best practices such as patient rounding, patient experience scores, patient safety successes, education plans and resources, competency systems and models, and opportunities for clinical care projects that could be done across both sites.” “Locally, our hospital is known for its response to the community needs, ability to serve both ambulatory and acutely ill patients, and the ability to connect patients to other services when needed including our tertiary affiliation with the University of Utah. Our ability to build relationships across systems promotes better patient care and supports employees who are providing that care with connections, resources, contacts, and opportunities to improve care across systems.” Deborah Gaspar, CNO Memorial Hospital of Sweetwater County Rock Springs, Wyoming

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Beyond the contrast in volumes and patient mix, a common difference between large health systems and community hospitals is the type of resources used by the nursing staff. For example, during the labor and delivery clinical training, nurses from Blue Mountain Hospital in Blanding, Utah, were interested in our postpartum hemorrhage carts, and worked with us to adapt the design and contents for their own hospital. “Anyone can take their own resources for granted, so it’s always great to see what other groups are doing and share ideas,” said Kim. As to her overall experience with the rural nurse training program, Kim is enthusiastic about the partnership. “I can honestly say that I could never do what our rural nurses do. I have a newfound respect for rural hospital nursing.”


Changing the conversation: Brenda Bartholomew, CNO at Gunnison Valley Hospital and nurses Barbara Hyett and Heather Anderson embrace the value of bedside report for patients.

02. Talk with the patient, not about the patient. Making the bedside a focal point for communication

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In her standing report to the hospital board, Brenda Bartholomew, CNO for Gunnison Valley Hospital in central Utah, summed up her recent project in one sentence: “Oh boy, this was a big one!” That “big one” was moving the shift report from the nursing station to the patient’s bedside, while at the same time changing the overall shift times for all nursing staff. “For whatever reason in the history of our hospital, our shifts were 5:00 am to 5:00 pm,” said Brenda. “To do bedside report, we needed to change our shifts to 6:30 so that patients and their family members could be involved.” For nurses on the day shift, the time change meant adjusting evening activities, and for many nurses on both days and nights, changes like day care arrangements would be required. One of these initiatives alone would have been enough to tackle, so launching them together required a lot of pre-planning and communication with the staff about what bedside report means to the patients and to the nurses.

Bedside report benefits patients and caregivers Brenda was not the first in the country to move her nursing staff to a bedside shift change report—she joins a growing number of hospitals who see the benefits for patient safety and involvement in the care process. The philosophy of bedside report is to have the off-going and on-coming nurses give report with the patient and family members. Patients see and hear from the team of professionals who are providing their care, they feel more informed about the care plan and less anxious, and they know that their situation is being monitored from shift to shift. At Gunnison Hospital, “we’ve found that beside report reduces the perception that no one is around during shift changes when sentinel events are more likely to occur.” For staff, there are many benefits to bedside report, starting with the gift of time. Many organizations report that their nurses are initially concerned that bedside report will take too much time, but the reality is that the brief time for report is more focused and many tasks are accomplished that free up time later in the shift. While together, the off-going and on-coming nurses update the whiteboard, check the IV lines and other equipment, ensure the call light is within reach, check the bed

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“ Nurses began hearing from the patients how much they loved bedside report, nursing accountability from shift to shift was improving, and our patient satisfaction scores were climbing. Our nurses were coming on board!” —Brenda Bartholomew, CNO Gunnison Valley Hospital Gunnison, Utah

rails, and review the patient’s chart and current status. The bedside report is also an opportunity to improve accountability from shift to shift. If a nurse goes in to a room and sees that the last nurse has left it in disarray, she can gently direct her co-worker to finish their tasks: Why don’t you empty the urinal while I update the whiteboard? “If I as a staff nurse understand that bedside report is an expectation and know that my coworker is going to be checking both my patients and my rooms, as well as verifying my charts, then I am going to be more likely to ensure everything is in order before that shift change,” says Brenda. Planning for the change started about six months prior, and making the change actually stick took another six months. But it was worth it for Brenda and her nursing staff. “Nurses began hearing from the patients how much they loved bedside report, nursing accountability from shift to shift was improving, and our patient satisfaction scores were climbing. Our nurses were coming on board!” In fact, it was one of Brenda’s nurses, Barbara Hyett, who shared Gunnison’s bedside report success with Margaret Pearce, CNO for University of Utah Health Care. “What impressed me about my conversation with Barbara is that she was honest about being resistant to the change, but described how she had


Gunnison Valley Hospital HCAHPS scores (percentile) Transition of care

99

Willingness to recommend the hospital

99

Overall rating of hospital

95

Communication about medicines

84

Pain management

98

Responsiveness of hospital staff

98

Communication with doctors

99

Communication with nurses

99 0

25

50

75

100

The new norm: A year after implementing bedside report, all but one of Brenda’s HCAHPS scores changed for the positive, and today her scores are still going strong.

100 90 80 70 60 50 40 30 20 10

changed her mind after seeing bedside report in action.” Margaret’s team had already been learning from Emory University about their beside report process, receiving valuable teaching aids and insight. “In talking with Brenda’s nurses, I knew right away that her team would be able to add another perspective that would help us in our journey with bedside report.”

Pay it forward Planning began immediately for a site visit, and nursing leaders from the University of Utah headed down south to Gunnison Valley Hospital to observe and learn from Brenda’s staff. “They were so engaging with the patients and the process was so smooth. I can’t wait for us to get there—to have it go that smoothly here,” said Colline Prasad, Nurse Manager for the Surgical Specialty and Transplant Unit. “I really liked the way the nurses worked together with the nursing assistants—it was a great team approach.” Scott Christensen, Associate Director for Acute Care and Rehab agreed that the team approach was a standout.

“A nursing assistant brought an issue to the bedside report that both the patient and nurse had missed, which showed that everyone had value to the process and could contribute.” After watching the Gunnison nurses, Colline said that it was hard to imagine any other way to give report. “There’s a difference between giving a traditional report at the bedside, and doing bedside report. It’s not just a geography change, it’s a philosophy change. And it’s clear that Gunnison nurses have changed their philosophy. They are giving a true bedside report.” In fact, the process was so hard-wired, that bedside report happened even before the patient got to the bed. “They had a patient who was in surgery at the time of shift change, but the nurses still went to the room that they were preparing for the patient and gave report,” said Teri Olsen, Director of Planning and Execution for Nursing Services. “It really felt like they were caring for the patient before the patient even arrived. It was great!” Scott agreed that the processes were indeed well embedded. “They did have the culture that we don’t have quite yet.”

0 Always

Usually

Sometimes

Never

2014 NURSING REPORT / 9


KLIST

RT CHEC E REPO Patient Prepare

BEDSID

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riefing

Safety B ns troductio

1. In

BEDSIDE

REPORT CHECKLIS T Prepare Pa tient

- Ensure fam ily underst ands BSR - BSR with Q caregive r change Prepare pa tient - Pain - Po tty - Positi oning - 2 hrs. IV fluids - Fre sh H2O in reach Charting Tas k I&O, summa list, orders, eMAR, ry of clinica l course

nt Data w Patie computer 2. Revie Safety Brief w data on mily what you ■ Revie ing tient/fa pa ck to to Explain turning ba oid 1. Introduc av — tions are doing all possible at d on ge patient if log 2. Review must be Patient Da oing RN ies ■ Re ta ■ Off-g view data ds, therap on compute tasks, me Explain to r ■ Verify patient/famil leted al mp y what you are nic co cli doing—avoi are portant s d im tur ce te nin tan g back to unica circumspatient if at all possi or ■ Comm ts ble ing tes ■ Off-go data/pend ing RN mu st be logge d on ■ Verify tasks, meds SBARQ h , therapies 3. Verbal s pertinent healt are ily co mp fam leted us tient and ■ Disc ■ Comm n with pa art unicate ch of informatio sive review data/pending important clinical an exten tests or circ ■ Not le umstances acceptab g notes 3. Verbal SB ■ Takin ARQ ssment ■ Discuss pertinent se As d health informatio 4. Focuse d per DX n wit ete s, etc. h patient and family ■ Targ drain t an exten unds■, No k lines, wo : MDRO,sive review of chart ■ Chec tions ■ Tak au ec ing pr no y te tes acceptable w safet ■ Revie appropria PPE as4. Fo ands cusede Fall, Skin, d rst Assessmen ng RN un t re oncomi ■iftTargeted pe ■ Ensu r DX sh r ed fo ■ Check line care need s, wounds , drains, etc en ■t Reviewho . are we wety Managem CAPA - saf 5. Pain eFa Skin, ard precautions: MDRO PPE as ap ussion us - ll,wh , ite bo ■ Disc pro pri als ate go t ■ Ensur e oncomin doing - se g RN unde care netie nt rstands th Pa eded for s ft resshi tting wi og Se Pr al ard 6. Go 5. ite Pabo like on wh in Mana uld ■ Goal gement e you wo ■ Discu ing els ssion use ■ Anyth CAPA - ho ss? doing - set w are we to discu goals - wh ite board 6. Goal Se tting with Patient ■ Goal on whiteboa rd - Progre ■ Anyth ss ing els to discuss? e you would like

For the University of Utah, lessons learned from Brenda and her team were incorporated into the rollout of bedside report at the University Hospital last fall, and bedside report has been in place for almost a year. Our patients’ reaction to the change is reflected in our HCAHPS results. “We have added a question about bedside report, and have been able to correlate the data,” says Margaret. “When we always give bedside report, our scores are above the 90th percentile for nearly every question. The scores drop dramatically if we aren’t consistent in bedside report. Clearly the patients want and value the bedside report process.” And for Brenda, her work on bedside report with the University of Utah has recently come full circle. “My mother unfortunately had a stroke a couple of months ago and was transported to the University of Utah hospital from Central Valley Medical Center.” Brenda asked her mother about the U’s bedside report. “She really liked it and thought it was very helpful to her in understanding what was happening with her care. She also felt that it gave her the opportunity to ask questions. She is doing great and luckily has no side effects from the stroke.”

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Bedside Report Correlates with Success at University of Utah Health Care Like most hospitals, University of Utah Health Care has been on a journey to discover the best solution to exceeding our patients’ expectations using the HCAHPS survey (Hospital Consumer Assessment of Heathcare Providers and Systems). We realized we were doing well in many metrics, but as nurses we struggled in two areas: Nurse Communication and Pain Management. While our culture valued and measured individual patient experiences and individual provider autonomy, the HCAHPS tool was more about measuring standardized processes—did we ALWAYS provide the same great experience to every patient? We needed to change our culture from one that only valued the individual caregiver and their personal style, and move toward a consistent, every day, every time, every patient experience. Not an easy task with 2,000 bedside caregivers. As we were working on this daunting problem, our Women’s and Children’s service line director, Rita Aguilar, and her team proposed a solution: communicate consistently with the patient and family by taking our change-of-shift report between the off-going and on-coming nurse from the hallway to the bedside. We were not the first to do this. In fact, bedside report was a common method of changing shift in the era before computers. We investigated further and found that Emory University had adopted bedside report, and they generously shared their information, successes, and bumps in the road with us. Using the lessons learned from Emory, we put together the things we felt were vital to a great communication process—our bedside bundle—and began to make plans to implement bedside report throughout the system. Just as we were preparing for the rollout, we met two nurses from Gunnison Hospital in Gunnison, Utah, who were here for PICC line training. When Margaret Pearce, our CNO, mentioned our plans to begin bedside report, they said, “oh, we do that at our hospital.” Margaret asked how it worked for them and they gave us great encouragement, “at first we pushed back, but after


Transition of care

99

Willingness to recommend the hospital

99

Overall rating of hospital

95

Communication about medicines

84

we tried it, we love it.� And their HCAHPS scores are Pain management excellent.

Responsiveness of hospital staff

We immediately asked if we could come to their Communication with doctors hospital and learn how they do bedside report, and nurses they welcomed us down to see Communication their process with in action. That firsthand experience was invaluable to our nurses, 0 and helped them understand that they could overcome perceived barriers of lack of time and eased their

concerns over this change in practice. We implemented 98 bedside shift report by first conducting multiple 4-hour 98

mini-retreats (2 hours of training and 2 hours of 99 and went practice) for all of our nurses. We set the date

live in all acute care units followed quickly99by the critical care units. Our patient satisfaction results have proven 25

50

75

100

the value of bedside report, with positive outcomes when we always do bedside report.

University of Utah Health Care HCAHPS scores (percentile) 100 90 80 70 60 50 40 30 20 10 0 Always Recommend hospital

Usually Communication with nurse

Sometimes

Never

Pain management

Bedside report works for the patient. When the patient reports that their nurses always gave shift report at the bedside, the HCAHPS percentile rankings for key questions are dramatically higher than when the nurses usually, sometimes, or never give report at the bedside. Results shown are from our project start of May through August 2014, n=1,123.

2014 NURSING REPORT / 11


Making an impact: Dr. Shannon Hess at Carson Tahoe hospital in Carson City, Nevada, provides tiny patients with top-tier care. Photograph by Jamie Kingham.

03. Give tiny patients a perfect start. Becoming a community leader in Baby-Friendly care “We did it!� This was the enthusiastic reaction of the staff at Carson Tahoe Regional Medical Center in Carson City when they became the first Baby-Friendly hospital in Nevada. Baby-Friendly status is a prestigious

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designation given to hospitals who meet requirements in Baby-Friendly USA in conjunction with the WHO/ UNICEF to promote and support breastfeeding for their newborns.


Sound easy? It’s NOT! “Historically, hospitals have unintentionally hindered the act of breastfeeding rather than protecting and promoting it,” says Mary Scott, RN, IBCLC, Lactation Consultant at Carson Tahoe Health. “Being BabyFriendly changes what our nurses and physicians do in the first few hours and days following delivery to ensure the best breastfeeding practices.” According to Baby-Friendly USA, only 182 hospitals and birthing centers in 42 states and the District of Columbia hold Baby-Friendly status. It takes a complete commitment to promote and support breastfeeding and includes 10 steps according to Baby-Friendly USA: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in the skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. 6. Give infants no food or drink other than breast-milk, unless medically indicated. 7. Practice rooming in–allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no pacifiers or artificial nipples to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.

On the surface, the Baby Friendly journey seems very straightforward with the 10 steps outlined. However, behind each of those steps is a series of processes, training, and sometimes a culture change, making it challenging for hospitals big and small. The journey can take several years and requires a strong commitment from not only the nurses, but also from administrators and hospital support services.

Most importantly, the process starts with passion— caring and committed nurses passionate about giving babies the best possible start. “We started our journey towards Baby Friendly designation years ago and in 1997 we were pretty much ready, with the last major hurdle being the staff education,” said Shelly Koontz,

First hospital in Nevada Carson Tahoe was the first hospital in Nevada to achieve Baby Friendly status.

labor and delivery nurse and International Board Certified Lactation Consultant. The required training was daunting, amounting to over 1,500 combined hours for all of the nursing and assistive staff. Bringing in onsite programs was expensive, as was sending nurses offsite to education providers. “Back then, online training just didn’t exist.” Rather than giving up, Shelly and her colleagues pressed forward, providing BabyFriendly level care and strengthening new processes in preparation for the time when they would be able to finalize their application.

Drive to the finish line That opportunity came in 2009 when online training became available. But like so many nursing challenges, this one boiled down to resources. The online program itself came at a hefty cost, and all of those training hours would have to be paid as non-productive time. After thinking through possible next steps, the nursing team decided to reach out to a familiar partner for help—the Carson Tahoe Health Foundation. “It took very little selling—the unit nurses were so impassioned about the impact that Baby Friendly would have on our patients and the community, and the data backing their passion was impressive,” said Kitty McKay, Development Officer. “The Foundation acts as a vehicle of support for important projects that might not naturally have a funding stream, and clearly Baby Friendly was a vital initiative that needed to happen.” The Carson Tahoe Health Foundation, who supports the hospital’s goals through fundraising and community partnerships, quickly recognized the value of Baby

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Friendly practices to the community. Soraya Aguirre, President of the Board at the time, remembers the request well. “Given all the studies demonstrating the numerous long-term health and wellness benefits that result from successful breastfeeding, the Board found it easy to unanimously vote in favor of funding the Baby Friendly initiative. To us, the scope of the program which covers initial education for new mothers while in the hospital, and then extends to lactation support beyond the hospital walls, was especially compelling. The continuum of care built into the program made sense to us as the means for achieving long-term success and maximum impact.” So with generous support from their hospital foundation, and online training finally available, the Baby Friendly team began the education process and final drive toward Baby Friendly status. The entire team attended both hands-on and online training. “Our labor and delivery nurses have all undergone at least 20 hours of breastfeeding education and five hours of hands-on training,” said Mary Scott. “We want to make sure our new mothers are getting good, correct breastfeeding help.” They also finalized new policies and procedures, and after a rigorous site survey—and years of unwavering commitment—they achieved the long awaited Baby-Friendly status.

Meaningful for patients and staff When asked about the impact of the designation for Carson Tahoe, Nurse Manager Deborah LeBalch replied “we are seeing patients coming to us from outside of our region because we are Baby Friendly, and nurses have sought us out as well, wanting to work in a Baby Friendly organization.” But most importantly, the care providers have been able to get their tiniest patients off to the best possible start. “These evidence-based processes, like immediate skin-to-skin contact with mom or dad which calms and stabilizes baby’s vital signs, helps them to transition to life on the outside much quicker. It’s all about what’s best for the baby.” Achieving Baby Friendly status is especially meaningful for Anna Anders, Chief Nursing Officer. “I knew nothing of Baby Friendly when I came to Carson Tahoe several months ago,” said Anna. “As the Chief Nursing Officer, I am very proud of the accomplishments of the staff to

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“ It took very little selling—the unit nurses were so impassioned about the impact that Baby Friendly would have on our patients and the community, and the data backing their passion was impressive.” — Kitty McKay, Development Officer Carson Tahoe Health Foundation

turn this great program into a reality and to know that our hospital is committed to the best evidenced-based care for our mothers and babies.” And on a personal note, Anna reflected, “I personally failed at breastfeeding as did my daughter 6 years ago, so I am especially proud that the outcome will be so much different for our mothers and babies as a result of Carson Tahoe’s Baby Friendly environment.”


Sharing valuable information: CNO Lynn Kirman from St. John’s Medical Center in Jackson, Wyoming, leads staff in a daily huddle to maintain an informed and cohesive workforce.

04. Stand up for patient safety. Making patient safety an organizational priority At St. John’s Medical Center in Jackson, Wyoming, the leadership team is standing up for patient safety— literally. “We started in a bigger room that had chairs, but we found that our process works much better in a smaller space with standing room only,” says Lynn Kirman, CNO and Patient Safety Officer at St. John’s. That process is the hospital’s daily safety huddle, created as a way to improve communication about safety issues.

And it works beautifully. Every weekday morning at 9:15, an interdisciplinary team including ED, ICU, facilities and housekeeping, home health and hospice, skilled nursing, lab, cardiopulmonary, radiology, social services, quality, infection prevention, risk management, pharmacy, materials management, rehabilitation, and clinics comes together for a brief huddle to review any safety issues that have occurred in the last 24 hours

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and potential safety issues that may occur in the next 24 hours. Because St. John’s participates in Healthcare Performance Improvement (HPI) Patient Safety initiatives, the daily huddle was a recommended strategy that they adopted. “It wasn’t uncommon for a leader to hear about a problem through the grapevine, which often resulted in misinformation,” says Lynn. “They felt caught off-guard not knowing about incidents that could affect patient or staff safety. “ The daily huddle has not only preempted the grapevine, but it has also provided a forum for education about how to handle issues by discussing the actual or near miss events in huddle. “Isolated departments such as the lab are able to interact with those they normally do not see. Pharmacy and nursing are especially positively affected to deal with medication events more quickly.” As the word got out about the huddles, more departments expressed interest and were added to the standing meeting, and conference calls enabled off-site clinics to participate.

A quality partnership: RN Paige Jannsen provides exceptional care in a growing oncology unit at St. John’s Medical Center in Jackson, Wyoming.

The agenda for the 10-minute huddle is very simple: each attendee quickly shares any incident from the previous day, and any concern about the rest of the current day. As needed, problem-solving occurs and tasks are taken back to teams to resolve or prevent issues. A great example of how well the huddle works happened last winter during a blizzard. The materials department had a delay in supplies because of the weather and was able to inform the group about a work-around. At the same time, home health was worried about getting care to some of their patients,

Long-distance partners in patient safety “The Huntsman Cancer Institute at the University of Utah Health Care has a long history partnering with oncology nurse colleagues at St. John’s to keep cancer patients safe during their cancer treatment and as close to home as possible.

and there were staffing issues because a mountain pass

Huntsman has provided education support through

road closure affected staff members traveling in for

Chemo/Biotherapy classes and networking with

the night shift. Because all of the leaders where there

nurses in clinic, and the St. John’s nurses provide

together, there was broader critical thinking, they could all participate in the solutions, and everyone knew what the plan was right away.

Broad support for a brief meeting Prior to implementing the daily safety huddle, a survey with a comment section was distributed to hospital leaders. The feedback indicated that most leaders found

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high-quality care to patients and keep a strong continuity of care when their patients need come to Huntsman. It has truly been a win-win for patients and staff at both hospitals.” Susan Childress Director, Oncology Nursing Services Huntsman Cancer Institute


out about a safety event or issue from someone in their department through word of mouth. And while rumors are often more entertaining than facts, the leaders felt that they did not have a good idea of all of the safety events occurring in the hospital and wanted more solid information. After a trial phase for the daily huddle, the survey was re-distributed and the results were overwhelmingly positive: 100% of participants wanted to continue the check-ins, stating that they usually know all of the actual safety issues that occurred within the last 24 hours. There is currently 95% attendance for the huddle.

“ We moved to a smaller room with fewer chairs so we were not tempted to sit down and get comfortable, keeping the huddle short and to the point.” — Lynn Kirman, CNO and Patient Safety Officer St. John’s Medical Center Jackson, Wyoming

“The safety huddle was initiated in September of 2013 for a three week trial and was so successful we have not stopped,” says Lynn. The team did have to change the location and start time. “We moved to a smaller room with fewer chairs so we were not tempted to sit down and get comfortable, keeping the huddle short and to the point.” The group also planned the time adjacent to another critical standing meeting so they would be sure to end on time. “We have better communication because we all hear the same message every day and we are responsible for bringing the information back to our departments. The safety huddle has also improved relationships between departments as everyone hears what other areas are struggling with and we are able to offer support to each other.”

2014 NURSING REPORT / 17


Statewide alignment: Nursing Directors Jean Tealey and Tracey Nixon, along with the U’s College of Nursing Assistant Professor Brenda Luther partner with community and industry colleagues to create statewide solutions to workforce challenges.

05. Tap into talent statewide. Link local talent for statewide gains

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Imagine if you could tap into the other hospitals in your community, as well as local colleges, economic development groups, and workforce services to tackle your toughest staffing challenges. Now imagine if everyone was focused on solving the same problems, quickly. In Utah, this dream team is a result of the statefunded Utah Cluster Acceleration Partnership (UCAP), whose focus is on key industries as engines of economic growth and job creation. With healthcare identified as a key industry, UCAP brought together senior nursing leaders, academic faculty, government leaders, and other industry partners from across the state of Utah to hone in on top strategic issues for the state’s clinical workforce. “UCAP started as a way for higher education as well as state economic and workforce development agencies to respond to emerging industry needs,” notes Dave Buhler, Utah Commissioner of Higher Education. After analyzing the Utah workforce in the context of emerging healthcare trends, the UCAP team identified four areas of focus for health care, and pulled together working groups to tackle training and education around care management, medical assistant practice, nursing transition to practice, and innovations in clinical education and placements. “These teams made innovative contributions that will serve Utah’s medical community well into the future, and Utahns will benefit for years to come due to their hard work.”

Wanted: Experienced Care Manager, RN and Masters Degree in Care Management required. In the not-too-distant future, you will actually see candidates who meet this criteria, but today you would have a hard time because the academic programs simply don’t exist. That’s all changing thanks to the Nursing Care Management focus of the UCAP Healthcare initiative. “The care or case management focus has typically been around the inpatient episode, but health care reform has completely changed the way we look at things, and now we are concerned about what happens before you arrive at the hospital and what happens long after you leave,” says Tracey Nixon, Nursing Director for Capacity

Management. “Until now, the core nursing curriculum has not addressed care management and transitions of care, but our new program not only bridges the education gap, but it also addresses the industry workforce gap that is going to be critical sooner than later.” This new program is the Graduate Certificate in Care Management—a 3-semester online program created under the UCAP collaborative and currently being offered at the University of Utah College of Nursing. The class is all online, and anyone from across the state—or across the country can enroll. Brenda Luther, RN, PhD, is an Assistant Professor at the U’s College of Nursing, and led the UCAP team in the development of the program development. “The focus of this initiative was to create an interdisciplinary post-baccalaureate certificate and a Nursing Master’s track program in care management for nurses, social workers or other health disciplines to prepare them for an expanded role in managing patient populations with chronic disease, aging, and catastrophic illness.” The first cohort consisted of 8 full-time RNs recruited from four facilities: University of Utah Health Care, Intermountain Medical Center, IASIS, and MountainStar. The students represented a mix of experience levels in care management. As of the end of August, seven of the eight have completed the program, and the remaining student will finish this fall. Of these certificate graduates, five are continuing on for their Master’s degree, and by spring of 2015, all will be prepared to act as preceptors and care management leaders at their institutions.

Sharing across disciplines, across the state And care management is not just for nurses. “We are engaging other disciplines outside of nursing, which makes the program stronger,” comments Brenda. “For example, many courses are co-taught with gerontology faculty and our next cohort welcomes our first social workers.” The certificate program is also being offered through continuing and distance education, which further ensures that healthcare professionals across the state will have access to the program of study.

2014 NURSING REPORT / 19


Quick on the heels of the success of the certificate program, the UCAP team has finalized curriculum for a Masters Degree in Care Management for nurses who may or may not have previous care management experience but want to specialize in this emerging field of expertise. There will be 12 RN to MS students starting in the Fall of 2014 at the University of Utah, and the curriculum and programs of study have been shared with Weber State University, Southern Utah University and Utah Valley University, all of whom are interested in pursuing the offerings at their institutions. “This is a new method of developing and sharing a program within state educational institutions,” says Brenda. “The collaboration between industry and academics in the development of the care management curriculum has been phenomenal, and the feedback we have received as we presented our work both regionally and nationally has been very positive.” Tracey’s familiarity with the program goes beyond her work on the UCAP committee—she’s also a student in the pilot group. “Yes, I admit it. I’m my own human guinea pig!” jokes Tracey. “But it was great to experience both sides of the process. At work I am responsible for the care management function, so we had lots of conversations about what was really needed at a master’s level to provide better care management services to our patients.” As to the impact of her school work on her job responsibilities, she’s delighted. “I now have relationships with care managers across the state and the region, which helps all of us provide better care for our patients.”

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“ It was great to experience both sides of the process. At work I am responsible for the care management function, so we had lots of conversations about what was really needed at a masters level to provide better care management services to our patients.” — Tracey Nixon, Nursing Director Capacity Management University of Utah Health Care


Building our future workforce: U Medical Assistant Duffy Adams studies for the AAMA’s Certified Medical Assistant exam.

06. Break big challenges into practical parts.

Getting a handle on the evolving medical assistant role At least once a week, Jean Tealey will get a phone call from someone—a co-worker, colleague, provider, student, or community educator—asking her to clarify what exactly it is that Medical Assistants can and cannot do. Jean, Director of Nursing for the Community Clinics at University of Utah Health Care, is viewed as an inhouse MA expert: she has coordinated an MA training

program with the local community college, created an MA internship program, and employs in her clinics many of the MAs in the organization. But Jean wouldn’t exactly call herself an expert. “I’m definitely more informed than I was before, but I don’t think any of us understood just how complex and inconsistent the medical assistant field is when we first started this journey.”

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The journey Jean is referring to is the Utah Cluster Acceleration Partnership (UCAP) sponsored project focused on Medical Assistant Standardization. “We started this project a few years ago, discussing the future of the role of MAs and building our future workforce, especially in the context of healthcare reform. But we really picked up steam when we started talking about standardizing the scope of practice for MAs in the state.”

Clarify the boundaries Unlike nursing assistants, who have a clear scope of practice, the role of a Medical Assistant can be as varied as the places they are employed, from specialty clinics to physician practices. “It used to be that an MA would take a set of vital signs and then let the patient know that the doctor was on their way. But that’s just not the real world anymore,” says Jean. MAs can also help the organization’s bottom line. “In a capitated payment model, we want to keep patients from being readmitted, provide continuity of care, and appropriately manage urgent and emergent care. The Medical Assistant can provide essential functions like preventive screening, fall risk screening, and follow-up phone calls in transition of care. We have to embrace a top of license, or in this case, scope of practice for our medical assistants if we want to survive in the future.” So task variety isn’t necessarily a bad thing. In fact, organizations have a tremendous opportunity to leverage the medical assistant role going forward. But a defined scope of practice is needed not only to set the stage to prepare a growing workforce, it also provides for operational consistency and patient safety. Normally in Utah, the state’s Division of Occupational and Professional Licensing would be able to clarify scope of practice issues, but since MAs are not licensed, the group looked to industry expert Donald Balasa, Executive Director of American Association of Medical Assistants (AAMA) for feedback. “Because most medical assistants are delegated duties by physicians, in the majority of American jurisdictions medical assistants derive their legal authority to practice from state medical practice acts and/or the regulations and policies of the state boards of medical examiners.” In other words, scope of practice for MAs is largely determined by the provider under whose license the MA works. That said, Don points out that there are 3 key

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duties that cannot be delegated. “Medical Assistants cannot be delegated any duties that (1) constitute the practice of medicine or require the skill and knowledge of a licensed physician, (2) are restricted in state law to other health professionals, and (3) require the medical assistant to exercise independent professional judgment or to make clinical assessments, evaluations, or interpretations.” While the Utah Medical Association was willing to identify a few explicit tasks that Medical Assistants could NOT perform, they weren’t ready to tackle a comprehensive scope of practice, expressing the need for provider flexibility in managing their own practices. Until agreement could be reached at the state level, Jean worked with her fellow nursing leaders and human resource specialists to clarify and enforce the University’s MA scope of practice through job descriptions and other organizational structures. “Clarifying exactly what we want our MAs to do ensures that we have the highest competency for our employees and high quality, safe care for our patients. The bar is being raised for all positions.”

Provide consistent, quality education One of the overall goals of the UCAP initiative in all of the industries in Utah is to spur economic growth and create jobs. For the medical assisting field, jobs are burgeoning--the real challenge is preparing a qualified workforce to fill the jobs. AAMA’s Donald Balasa helped educate the team about current and future trends in industry certifications including the AAMA’s Certified Medical Assistant and the American Medical Technologist’s Registered Medical Assistant designation. The programs are standardized, robust and designed to promote ongoing competency. So, couldn’t we improve consistency and quality of MA performance statewide by simply making the certification mandatory? “If we mandated medical assistant certification today, it would adversely affect our community, both high school programs and Medical Assistant schools that are not accredited and could not offer this option for their students,” notes committee member Kelly Imlay, Chief Nursing Officer for Intermountain Health Care’s Medical Group. “In turn, this would hurt our physician practices throughout Utah and create a shortage of medical assistants who could meet this new education requirement.”


Meaningful use adds pressure

According to the UCAP project charter, the education landscape for MAs is a mishmash of institutions, programs and standards. Their analysis showed that more than half of MA degrees are granted by for-profit institutions (where tuition and program quality can vary widely). In Utah, several school districts offer courses in the high schools, and Salt Lake Community College is Utah’s only higher education institution providing an MA program. And as far as producing credentialed MAs, there are only 8 programs in the state accredited by the two nationally recognized accreditation bodies, which are the Accrediting Bureau of Health Education Schools and the Commission on Accreditation of Allied Health Education Programs. UCAP’s recommendation and ultimate goal would be to bring all public medical assistant training programs up to an accreditation standard, and to ensure that high school programs have a track that enables their students to sit for the certification exam. And in conjunction with improving the quality of training, we must inform potential students as to the importance of certification and choosing an appropriate education program. “There are several channels and options for educating our community and potential students,” said Kelly. “We can reach students through career websites, brochures in high schools, information for vocational counselors, and health science teachers. Our goal is to get the message out on the importance of MA certification for both the school and the student.”

For health care organizations participating in Meaningful Use, MA certification is a more immediate concern, since the Centers for Medicare and Medicaid (CMS) have mandated that only credentialed MAs can document orders in the electronic medical record. The result of this mandate is that working MAs who have not graduated from an accredited medical assisting program have no realistic way of meeting the CMS requirements1. Don’s board of trustees has concluded that the best way to assist these medical assistants would be by awarding an assessment-based recognition to those who meet certain knowledge and experience requirements and complete five AAMA continuing education courses (and pass the five post-tests) covering key knowledge elements of electronic order entry. Meanwhile, organizations can assess their own MA workforce, and start “preferring” certification for job applicants. Demand then influences the supply, prompting more education providers to become accredited. “Our work isn’t finished by far,” says Jean. “But now we have the community relationships to be able to move forward. This is a new level of networking, and it’s great!” Kelly agrees. “Having this experience working with the members of UCAP has been a wonderful way to bring community members together to focus on a common goal. It has been a great start to building a foundation for advancing the education of the Medical Assistant and their vital role they play in supporting our physicians and community.” 1

Working medical assistants who have not graduated from a

CAAHEP or ABHES accredited medical assisting program are not eligible for the CMA (AAMA) Certification Examination, and therefore have no realistic way of meeting the CMS requirement except through the AAMA Assessment-Based Recognition in Order Entry (ABR-OE). Graphic reprinted with permission from the American Association of Medical Assistants.

2014 NURSING REPORT / 23


07. See the science of work spaces. Building better prep areas for mother and baby Ask nurse Carol Henderson about breast milk, and you will instantly experience her passion about newborn infants and their mothers, and feel her pride as she describes the advances, improvements, and successes in the Newborn ICU. You also will be witnessing an example of the power of process re-engineering in the hands of an experienced nurse.

nurses faced of having a negative reaction to a positive situation, Carol started thinking about why the milk prep process was so challenging and began to tackle the issues as part of a lean project, employing tools and methodology she learned in the organization’s lean training program. “We expect so much of the nursing staff, that it can be a setup for failure if the environment and processes are not the best they can be.”

100%

A culture of continual process improvement

Preference for donor milk over formula for eligible mothers

5,000 ounces

Donor milk in the Newborn ICU during our program’s first year

“Rates for breastfeeding with nutritional additives have increased, which is good for the babies, but more time-consuming for nurses to prepare the various combinations of breast milk with fortifiers, powders, and other additives,” explains Carol, the Nurse Educator for the Newborn ICU. “Because of the poor proximity and layout of our milk prep areas, better milk for baby meant precious time away from the baby while the nurse prepared their milk. So unfortunately, it was often a cringe moment for the nurse to hear in report that baby was getting the good stuff.” Wanting to change the conundrum that she and others

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Process improvement activities have long been a part of nursing at the University of Utah Health Care, but a few years ago, we took our commitment for quality and efficiency to the next level, aligning our work with an organizational focus on lean. Dr. Vivian Lee, the Senior Vice President for Health Sciences at the U, called on leaders to embrace a culture of process improvement and value driven outcomes through the application of Lean and Six Sigma principles. Comprehensive training programs were delivered to leaders and front-line staff, and nurses were particularly eagerly to take part in the training. At the end of the training, participants develop individual improvement projects to put their newly gained skills to use. Throughout her project, Carol reached out to others in the hospital: business process engineers, unit and service-line leadership, infection control specialists, fellow nurses, building architects, and facility engineers. She and her teammates also visited the Denver Children’s


Reinventing boundaries: Improved organization and lean-inspired process guides help U Nurse Educator Carol Henderson and RN Katherine Barth improve quality and efficiency in the milk prep process.

Hospital. “It’s ok—and efficient—to borrow from others, especially if it’s the best thing for the patient.”

1st in Utah

While the quest to improve infant feedings is ongoing, the Newborn ICU has seen success in several areas this past year:

The University of Utah Health Care is the first to start

+

Redesigned milk prep workspaces

+

Identified and implemented best practices for milk prep rooms

+

Created a dedicated milk prep staff position to ensure accuracy and safety of the infant feedings

+

Created standardized mixing procedures and provided staff training

+

Researched and identified better refrigeration and warming equipment

+

Initiated a donor milk program

“When I hear our nurses using terms like soft-forcing function, and then they show me their pareto chart, and talk about the Hawthorne effect on the staff, I know

construction on a dedicated milk prep room in the state of Utah.

that lean has taken hold in nursing,” said Margaret Pearce, Chief Nursing Officer. “Nurses have always been involved in quality projects on the units, and are naturally inquisitive and methodical. The lean training we have rolled out adds some structure and tools to their toolkits, expanding their ability to tackle tough clinical problems.” In reflecting on the value of lean training, Carol comments “before the training, I hoped that my team members trusted me enough to believe my statements and recommendations. Now, I can back up my words with data presented in a visual way that is irrefutable. The lean language really gives my work more credibility and gives me more confidence.”

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A real-time process: Patient Placement Manager Spencer Steinbach discusses the day’s patient flow situation with Manager of Case Management Anne-Michelle Ferko and Patient Admissions Rep Chandler Warnick.

08. Get your patients coming and going.

Matching unit capacity with organizational demand One of the nursing teams most anxious to incorporate lean principles was the newly formed Capacity Management Team, which includes Nursing Supervisors, Transfer Center, Bed Board, Resources Nursing, Case Management and Social Work. “Just bringing these groups together in and of itself is a huge step towards

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improving our processes,” said Tracey Nixon, Director for Capacity Management. “It’s like our ability to coordinate with each other improved overnight.” With the new team structure in place, Tracey began reaching out to other organizations across the country to learn about current best practices in patient flow, and she


discovered an interesting approach from the Institute for Healthcare Improvement called Real Time Demand Capacity Management.

9% decrease

“Organizations typically have focused on discharges from day of admission to day of discharge, and we used to talk about the discharge needs of all patients every day,” said Spencer Steinbach, Manager of Patient Placement. “When you think about it, that’s a lot of effort coordinating what basically can be a moving target over say, a 5-day period. With the real-time demand process, we are focused on bringing together discharges for the day to align with the organization’s current capacity.”

76% accuracy

The real-time demand process draws upon queuing theory and the study of waiting lines and traffic patterns to identify critical points in time where patient flow can be improved. Basically, predicting capacity is a 24-hour process that starts the day prior to discharge when we identify patients to be discharged and actively manage their milestones overnight, for example, transitioning from IV to oral pain medication. The next day—the day of discharge—we huddle early to address potential discharge barriers and discuss unit capacity and demand. We also talk about those instances when a patient was scheduled to go home but didn’t. “We talk about where we missed the targets so we can learn,” says AnneMichelle Ferko, Manager of Case Management. “It’s not a punitive environment, it’s more about learning, opportunities, and change so we can get better at this.” In reflecting on how the role of case managers has changed under the new structure and method, AnnMichelle smiles. “The huddle provides a forum for Case Management, Nursing, and others to coordinate the plan for the day. We establish specific designees for milestones needed to complete the plan, and it is much more aligned and synergistic. It feels like everyone now has ownership of their individual piece of the discharge process.”

Transition from theory to practice As with most of our large-scale initiatives, the rollout of real-time demand capacity management started with a pilot in two nursing units. Since every organization is a little different, we wanted to test what we had learned and see if we had all of the pieces in place for University of

Discharges after 5pm

Predicting mismatches between capacity and demand. Through the implementation of Real Time Demand Capacity Management, discharge barriers and capacity needs are all tackled proactively, which reduces late discharges and helps units to open beds.

Utah Health Care to be successful. “Sometimes a process looks great on paper, but flops in practice,” says Tracey. “We wanted to make sure that didn’t happen, so we took time in the pilot phase to make sure we had addressed all of the real-life issues.” During the pilot, the units had a tendency to modify the process for their own staff, which is counter to the lean principle of standard work processes. “We wanted to reduce variation as much as possible, and realized that the education process that we had used to launch the pilot was part of the problem.” For education, Spencer had spent a lot of time in staff meetings teaching the new real-time demand process. “Not all of the unit nurses were there to hear the message, and as it turns out, our regular nurse-to-nurse hand-off communication method was not working for the real-time demand content,” said Spencer. “This turned out being one of those things that everyone had to hear at the same time from the same source.” Since Spencer couldn’t be everywhere for everyone, he approached the Nursing Project Development team to help him create a training video that could be assigned to all of the nurses through the hospital’s learning management system. This approach ensured a consistent and more indepth message about the new process. The training video included background information about what patient flow means to patients and to nursing staff, and covered the impact of flow to the financial viability of the organization. With the many attempts to improve patient flow over the years, there was naturally some skepticism about yet another new

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“ When the unit gets a call to take 2 more patients from the ED, they now know that they can impact their capacity by the way they are monitoring and preparing their patients for discharge. They are looking at the problem in a whole new way.” — Spencer Steinbach Manager, Patient Placement

approach. However, the training video provided a more global perspective that helped the nurses to link their capacity challenges to their own ability to move patients, and they were able to see the bigger picture. “When the unit gets a call to take 2 more patients from the ED, they now know that they can impact their capacity by the way they are monitoring and preparing their patients for discharge,” says Spencer. “They are looking at the problem in a whole new way.”

Consistency in patient communication In a final review of the training video before it was released, both the Capacity Management and Project Development team had a collective “ah ha” moment as Margaret Pearce, Chief Nursing Officer, watched the video to give her stamp of approval. In addition to foundational information, the video included a vignette showing how the morning discharge huddle works. “We were so proud of the video,” said Teri Olsen, Director of Planning and Execution. “It was well produced, great content, and we were ready to go. Then Margaret said ‘why is the discharge huddle taking place out in the hall?

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Wouldn’t it be better if they were at the bedside, talking about discharge with the patient?’ It kind of hit both Tracey and I like a ton of bricks.” And Tracey agreed. “It was like, of course! What were we thinking?” So, the video was re-shot, and the processes changed to move the discharge planning discussion to the bedside and include the patient, which has worked out remarkably well. “Talking with the patient and with your teammates in front of the patient puts you on your A-game,” says Spencer. Anne-Michelle also notes that moving discharge huddle to the bedside gives an opportunity to answer any related issues immediately. “One of our patients had received a letter of denial in error and he was very concerned. Because the right people were in the room at the same time, we were able to quickly troubleshoot the problem and have an answer for him before he left the hospital. Before our bedside approach, something like this would have taken a few days just in the communication back and forth.” For other groups looking at a system-wide change of this magnitude, Tracey’s advice is to first ensure a solid foundation, which for the University of Utah included lean principles. After that, “reach out and learn from other groups, be methodical in your education, dedicate a resource for the rollout, and be persistent. It will pay off!”


Working together for a timely discharge: U Physicians Jennifer Vanhorn and Julie Shakib are able to quickly view, visually commuicate, and plan discharges for both mom and baby.

09. Chart a course for home. Creating a visual discharge checklist for patients and providers

Getting a patient discharged and on their way home is a

“The comments we saw on our patient satisfaction

challenge for many healthcare systems. Add another tiny

survey confirmed what our nurses and providers

patient with a separate care team to the picture, and the

already knew: our patients were frustrated with what

discharge process gets a lot more complicated. Which

they perceived as unnecessary delays to the discharge

is what happens for moms and their new babies every

process,” says Rita Aguilar, Nursing Director for

day: OB physician checks on mom and tells her she’s

Women’s and Children’s services. “They were also

ready to go home, but the Pediatrician can’t discharge

frustrated with what they perceived as a disconnect

the baby even if the exam and assessment is normal until

between the OB and Pediatric care teams.”

scheduled time-sensitive tests are performed.

Dr. Karen Buchi, Chief of the Division of General

Now mix in federal guidelines for length of stay, and

Pediatrics at the University of Utah, was already

state health screening processes and timelines, and you

an advocate for lean, and was well aware of the

have a challenge worthy of a lean project.

communication challenges of mother-baby discharges,

2014 NURSING REPORT / 29


so she eagerly sponsored a lean project to improve the discharge process and care team communication in the Mother and Newborn unit. “Refining the discharge process on the Mother Newborn unit was an ideal project to engage our multi-disciplinary team in implementing the lean process and meet the call from hospital administration to become more efficient and improve patient satisfaction,” states Karen.

Fresh eyes, lean lens The lean project started with basic process mapping. “We created a comprehensive list of all of the milestones and tasks that needed to be complete to get mom out the door, and then did the same for baby,” said Terrie Dority, Nurse Manager for the Mother and Newborn unit. The team then looked at the required timelines for each task in the list, considered federal and state regulations, and started weaving the two lists together in one timeline, which exposed some prime targets for improvement.

“The newborn metabolic screening has long been an obstacle for us in getting moms and babies home as soon as they are ready and want to go,” notes Terrie. Historically, the Utah State Department of Health mandated that the screening be performed as close to 48-hours post delivery as possible. Since births occur at all hours of the day, so did the 48-hour newborn screenings, making it difficult to work into a regular routine. Terrie and her team decided to question the status quo and researched the clinical indications of the 48-hour window. To their surprise, they found that obtaining the test results at 48 hours was not as important to the state as was getting baby into the registry before discharge. “So basically, we could obtain the blood sample for the test anytime after 24 hours, which enabled us to define a better process with better timing.” With task lists for mom and baby defined, the project team then tackled the challenging issue of communication between the different care teams. White

The Spark Health Innovation Lab at the University of Utah started in 2011 when undergraduate students were challenged to consider ways to improve the patient experience using human-centered design principles. With support from the Technology Venture Department, Eccles Health Sciences Library, University of Utah Health Care and other campus sponsors, what began as a suggestion from a pre-med/business student came to life in the form of a patient-centered, multi-disciplinary innovation lab. Students Evan Howard and Brandon Bacon, along with their project team, were eager to tackle the communication board project for Rita Aguilar and the Mother and Newborn department. In addition to the content to be communicated, the team tackled physical issues ranging from creating surfaces that could be sanitized after every patient to making the board easy to manipulate, which ended up involving magnets instead of hooks to hold the milestone cards. After half a dozen prototypes, the team developed a workable model that was put to the test. Not only did it survive repeated cleanings with sanitizing wipes and other sterilizers, the look and feel was extremely user friendly—easy for the nurses to use and easy for the patients to understand. And the design just popped. It was polished and professional, and truly had the appearance of a commercially designed product. The patients aren’t the only ones benefiting from the Spark lab experience. Students are gaining valuable experience, putting into practice what they learned in school and developing solutions to very real problems. The Spark lab enables students from across campus to work closely with healthcare professionals, where they can learn firsthand how patients are impacted by processes and how they can improve the patient experience.

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boards in patient rooms have been a best practice for several years, and provide a way for information to be easily recorded and shared. The problem is that information is often not consistent or comprehensive, especially around discharge milestones. Erika Lindley, Administrative Director for Women’s and Children’s Service Line and the Department of Obstetrics and Gynecology, had already been scouting for solutions and had heard about a new communication board being used at Kaiser-Permanente. “I thought, gosh, there’s no reason we couldn’t do this here,” said Erika. “To get started, I reached out to our process engineers, and they introduced me to a student group on campus that specializes in innovative design and fabrication, and the students just happened to be in the process of looking for projects at the hospital.” That student group is the Spark Innovation lab at the University of Utah (see sidebar).

Partners in production “I was skeptical at first, working with undergraduate students, worrying that they would be able to grasp the complexity of the clinical problem we were trying to solve,” said Erika. “But they were eager to listen and to give us feedback, and by our second meeting, they had done extensive research on the concept including looking at the Kaiser solution.” The students suggested using the Kaiser-Permanente idea as a starting point, and they were eager to improve on the concept. Using the mother and baby milestones that Terrie’s team had identified, the Spark team went to work designing a communication board that would be efficient and effective, serve the needs of both the pediatric and OB teams, support the nursing staff, inform moms and families, all while fitting into the clinical environment. “Our clinical tools need to be easy to use, maintain, and clean,” said Rita, “and our new boards fit all of these criteria.” The board contains individual pieces that visually identify a milestone, like discharge education or home medications, as well as the owner of the task, for example nurse, OB provider, pediatrician, pharmacist. When a task is finished, that piece is turned over to show it has been completed, which provides the at-a-glance view for the patient, and a visual map of outstanding tasks for the care team. “When we first started our lean discharge project, we thought our biggest opportunity was speeding up the discharge process,

Communication at a glance: These easy-to-use and easyto-clean communication board tiles help to inform moms and families by visually mapping milestones.

which did happen, thanks to the new daily metabolic screening schedule. In reality, the larger opportunity was in improving communication with our patients, by educating new moms about all of the things that need to happen before they can go home,” said Terrie. The reactions to the boards have been overwhelmingly positive. “Patients love the boards, and so do the caregivers,” said Terrie. Even our accreditation agency was impressed. “Our DNV2 nurse surveyor was so impressed with our communication boards that she asked if she could share the idea with other hospitals,” said Rita. “She said that all patients should be able to see at a glance the status of their stay and readiness to go home.” As to the work of the Spark lab, Erika and Rita are continuing the collaborative effort, re-thinking patient brochures, education materials, and websites. “The Spark group compliments our clinical expertise with a fresh outside perspective and sharp design skills,” said Rita. “It really is a perfect match.” 2

DNV is the acronym for Det Norske Veritas, the accrediting

body for University of Utah Health Care.

2014 NURSING REPORT / 31


Establishing a path for aspiring nurses: U College of Nursing Dean Trish Morton and Assistant Professor Carolyn Scheese provide nursing student Jeff Steenblik with insightful clinical feedback.

10. Elevate your workforce.

Rounding out professional expertise Shortly after arriving in Utah and settling into her new role, Trish Morton, Dean of the College of Nursing at the University of Utah, began hearing a common question from members of the community: If there’s such a nursing shortage, why is the U turning down qualified applicants? It seemed as though everyone she met had a friend or family member with good grades and a story of rejection from the U’s nursing program. “It’s hard to explain to folks that it’s not only about the qualified and

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eager candidates, but we are limited in the number of students we can accept because we have only so many faculty members to teach them.” So, Trish and her Associate Dean for Academic Programs, Barbara Wilson, went to work re-examining college’s programs, reaching out to the University of Utah Hospital leadership, and getting creative about opening up capacity at the college. After all, 2020 is just around the corner.


Learn, practice, teach; repeat Expanding competencies in areas like community and public health and health policy were key aims of the 2010 Robert Wood Johnson Foundation and the Institute of Medicine’s recommendation that 80 percent of nurses be bachelors prepared by the year 2020. At the University of Utah, we have about 300 nurses to guide through a bachelors program in the next 5-6 years, the majority of whom come from our own internal Future University of Utah Nurses effort (see our 2011 Nursing Report, story #4). “Over the past several years we have been able to help over 200 staff members from all over the organization become nurses,” said Margaret Pearce, Chief Nursing Officer, “and it was always our goal to help them continue their education here at the U. Barbara and our colleagues at the College of Nursing have been wonderful in bridging the transition from associates to bachelor’s degree for these employees.” Carolyn Scheese, Director of the RN-to-BS program at the College of Nursing has been especially helpful in leveraging the long-standing online program at the college to help practicing associate-level nurses obtain their baccalaureate degree. “We have reengineered our online RN-to-BS program and made it feasible for working nurses to more easily complete their baccalaureate degree.” The online program provides the University of Utah Health Care nurses the flexibility to fit education into their work schedules, and the curriculum, which can be completed in as few as 15-16 months, prepares the nurses for a seamless transition to several graduate programs. “We are now investigating a new option that would allow a nurse who is able to attend school full time the ability to complete their bachelor’s degree in just two semesters (8 to 9 months),” says Carolyn. The new options would allow students to start the program twice a year and provide greater flexibility in the scheduling of their courses. Advancing the education level of our licensed nurses is an important goal, but we also need more nurses as the market shifts (again) from surplus to shortage. Now here comes the tricky part. As Trish noted, in order to educate more nurses, education programs must increase capacity, which requires more faculty—masters and doctorate prepared nurses—which ultimately takes us back to

where we started with the need for more bachelorprepared nurses who can progress into advanced degrees. And, to accommodate additional nursing students, we will need more clinical placements, clinical instructors, and practicing nurses to pair with students.

“ We must prepare nurses to be clinical experts as well as leaders, and be a voice for the health care system of the future.” — Margaret Pearce, CNO University of Utah Health Care — Trish Morton, Dean University of Utah College of Nursing

Tangled challenges like these were explored earlier this year in a day-long retreat between the College of Nursing leadership and the health system’s Nursing Executive Council. “Our day-to-day work is very different in nature, but we intersect at many crucial points, and it’s going to take all of our creative energies to prepare for the future,” said Margaret. With oversight for the college’s undergraduate and graduate academic programs, Barbara Wilson has been quick to respond to the educational needs of Margaret’s workforce. “We’re eager to partner with our colleagues from the University of Utah Health System,” says Barbara. “We believe our online RN to BS program will help Margaret and her teams meet the challenges they will face with decreasing reimbursement and higher demands for excellent patient outcomes. We know from several recent studies that patient outcomes are improved with an increase in the number of nurses with baccalaureate degrees. We want to help.” In their first year of collaboration with the new dean, the health system has provided funding for two additional faculty and expanded clinical slots by 40%, which includes adding experiences in the community clinics for

2014 NURSING REPORT / 33


nurses in the community nursing rotation. The college in turn has been able to increase RN-to-BS capacity by over 60% adding slots especially for University of Utah Health Care employees, as well as a part-time master’s program for practicing nurse educators. The college is also taking advantage of their state-of-the-art simulation center to ease the pressure on clinical placements for first semester traditional nursing students, and the hospital is helping to identify nurse practitioners across the system who can serve as preceptors for the advanced practice students. In preparing for the future, Margaret and Trish agree on their shared responsibility. “We must prepare nurses to be clinical experts as well as leaders,” said Margaret, “and be a voice for the healthcare system of the future,” adds Trish.

An Epic education event We all know that nurse training and education doesn’t end once a nurse enters practice, and this year our nurse training efforts were truly Epic—literally. After years of planning and months of training, we moved from separate clinical systems for inpatient, surgical anesthesia, radiology and pharmacy, to a unified electronic medical record on the Epic foundation. Epic systems have been in place for well over a decade in our ambulatory settings and over 3 years in our business offices (e.g., scheduling, billing). With thousands of clinical caregivers to train, the transition to Epic system-wide, which we refer to as One Chart, was an organizational priority, and to ensure success in the nursing department, we reached out to trusted familiar

An Epic transformation: After a highly successful system go-live, U Nursing Director Lori Larsen and Nurse Educator Gina Stevens discuss upcoming system enhancements.

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faces who had helped us succeed in the past—our own nurses. “It certainly didn’t hurt that we hired Lori away from the IT department,” joked Margaret, referring to Lori Larsen, Director of Nursing Informatics, who was recruited a few years ago from her role as a senior project manager in the information technology department. “Kidding aside, we have a great relationship with the IT department, and they knew it would help both of our teams to have Lori leading the way from the nursing side.” Lori’s team of 16 is comprised of informatics nurses and medical assistants, medical claims adjusters who continually review charts to identify gaps in documentation that impact quality metric reporting and revenue capture, and a scheduling and payroll specialist who, during the One Chart project, managed the transfer of staff hours from across the organization to the centralized nurse training budget.

No training, No access. No kidding. Reflecting on the readiness of the nursing department, Lori commented, “We were lucky in that we already had a strong foundation to start. We were live on an electronic chart, and had gone through many upgrades over the years, so we really could leverage our past experience.” That experience had reinforced the importance of solid advance planning for education of the nurses, and for this project, the Epic organization had tools to calculate the number of training hours needed, as well as starting points for lesson plans and other learning materials. The challenge was in the number of training hours required by Epic for a successful go-live. Given that we had over 2,000 nursing staff to train in a 2-month period, Epic’s calculator estimated that we would need far more trainers than Lori’s team could provide, and more than the central IT training team had available to devote to nursing, as they were also responsible for all providers and support staff as well. When the U converted to the Epic system for business operations, the organization adopted a “no training, no access” policy to ensure successful implementation of the new system. The notion that training would be optional for the clinical Epic modules was not even a consideration despite the challenges of securing enough training resources. So, Lori and the nursing executive

team worked together to identify an adequate number of nurses on the units who would receive rigorous training in the Epic applications to become “credentialed” trainers. These credentialed trainers, were then approved by Epic to train other staff in the organization. In addition to the credentialed trainers, several extra staff in each unit were trained as GoLiS (pronounced Goalies), which is short for Go Live Specialist. The GoLiS were pulled out of clinical assignment so that they could focus on supporting their unit, and all units were asked to staff to capacity and put vacations on hold leading up to and throughout the go-live.

Number of nursing staff trained: 2,128 Total nursing training hours: 20,937

After years of detailed planning, months of training and communication, support from across the organization, and hours of dedicated attention, the University of Utah Health Care experienced a highly successful Epic implementation. For nursing, we have been able to bring inpatient and ambulatory nurse charting together for true continuity of care. We have also been able to embed tools to support high priority nursing initiatives including our bedside report process and pain management conversation tool. And for the nursing staff, their culture of innovation and improvement was evident as nurses transitioned quickly to the new system. “In fact,” laughs Margaret, “the go-live was so successful that the nurses politely asked the management team to stop rounding because they didn’t need any support. They kind of said, enough already! We’ve got this!” “We were truly the little engine that could,” says Lori of her team, who worked tirelessly to ensure success. “We always asked ourselves -- What else? What have we not thought of? What are we forgetting?” As to what’s next for Epic, “We know that we will always be optimizing, upgrading to enhance functionality or to improve patient safety. Fortunately, we have a nursing workforce that is agile and adept at change.”

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It’s your turn to share. As always, we invite you to share your stories of reaching out to new partners in the journey to improve the care we provide our patients. Join us online at NursingInnovation.UofUHealth.Org or email NursingInnovation@hsc.utah.edu. We want to extend a special thank you to our affiliate partners in the Mountain West:

Deborah Gaspar, CNO Memorial Hospital of Sweetwater County Rock Springs, Wyoming Robert Kendrick, CNO Madison Memorial Hospital Rexburg, Idaho Angela Booker, CNO Teton Valley Health Care Driggs, Idaho Anna Anders, CNO Carson Tahoe Regional Healthcare Carson, Nevada Lynn Kirman, CNO St. John’s Medical Center Jackson, Wyoming Kristin Gundt Community Hospital in Grand Junction Grand Junction, Colorado Amy Deeds, Megan Makelky Sublette County Rural Health Care District Pinedale, Wyoming Kent Turek, CNO Blue Mountain Hospital Blanding, Utah

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2014 Nursing Report Production Team

Executive Editor Margaret Pearce, RN, PhD Chief Nursing Officer University of Utah Health Care Production Manager Maiko Taguchi, Project Administrator University of Utah Health Care Writers Teri Olsen, Director of Planning and Execution University of Utah Health Care Margaret Pearce, RN, PhD Chief Nursing Officer University of Utah Health Care Designer Sandy Kerman, Kerman Design Cover Art Kirsten Chursinoff Photographer Derek Larsen, Multimedia Project Administrator University of Utah Health Care Multimedia Brian Gresh, Senior Director Interactive Marketing & Web University of Utah Health Care Derek Larsen, Multimedia Project Administrator University of Utah Health Care Additional Project Support Jennifer Parson, Administrative Assistant University of Utah Health Care Phil Sahm, Public Relations Specialist Public Affairs University of Utah Health Sciences


NursingInnovation.UofUHealth.org

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University of Utah Health Care Nursing Report 2014  

University of Utah Health Care is dedicated to collaboration. And the 2014 Nursing Report highlights not just our own innovations, but also...

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